The WellMed2U RN/Case Manager coordinates care and provides initial ongoing nursing assessment of the patient and family needs and coordination of the patient’s plan of care with interdisciplinary team members and the WellMed2U APC.
- Conducts medical home visits with or without telemedicine technology on established WellMed2U patients performing a hands-on exam at each visit
- Conducts urgent/acute visits on established WellMed2U patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home
- Provides ongoing assessments of the impact of chronic illness on the patient’s physical, functional, psychosocial and environmental needs
- Provides ongoing telephonic assessments and intakes for high risk patients and incoming calls regarding acute issues
- Assesses for caregiver burnout, and provide community resources when appropriate
- Implements the individualized plan of care and recommend revisions to the plan as necessary
- Ability to perform procedures, to include, but not limited to:
- Wound care and dressing changes
- Injection (B12, vaccines)
- Ability to conduct an advanced care discussion with a patient and their family and properly document their wishes in the electronic medical record
- Consults and educates the patient/family and other caregivers regarding the disease process, pain and symptom management and other clinical needs
- Initiates appropriate preventive and rehabilitative nursing procedures when appropriate
- Ensure continual assessment of patient and family needs from admission to WellMed2U and throughout the course of care
- Provides ongoing evaluation of the patient and family/caregiver response to care, and recommends alteration of the plan when necessary
- Attends the interdisciplinary meeting and is a crucial and vocal member of the team
- Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Decision making is usually based on prior practice or policy, with some interpretation. Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures.
- Conducts telephonic nursing follow up and case management when necessary
- Serves as a resource or consultant for LVN (where applicable)
- Attends educational offerings to keep abreast of high risk and special needs patient care and complies with licensing requirements
- Establishes a trusting relationship with identified patients, caregivers, clinic staff members and physicians
- Collaborates with the providers to recommend policies, procedures and standards which affect the care of the WellMed2U Patient
- Exhibits professionalism and is courteous with all patients, physicians and co-workers
- Informs the provider of patient’s needs and outcomes of interventions as per standards
- Coordinates all patient/family services and prioritization of needs with the members of the interdisciplinary team
- Documents in the electronic health record progress toward established goals as per standards
- Uses the case management approach and refers to other services as needed
- Maintains a patient case load, daily visits and point of care documentation levels as per standards
- Participates with the on-call rotation schedule and weekends as assigned
- Performs all other related nursing duties as assigned
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
- Registered Nurse with a current unrestricted license to practice in the state of employment
- Five or more years experience in a physician’s office, clinical, hospice or hospital setting
- 2+ years of home health/hospice experience preferred
- Current BLS certification
- Reliable transportation
- Demonstrated experience of excellent nursing skills
- Proficient knowledge of chronic illnesses
- Ability to use SBAR method to discuss care with clinicians
- Experience related to advanced care planning and discussions with patients regarding end-of-life wishes
- Excellent verbal and written skills
- Ability to interact productively with individuals and with multidisciplinary teams
- Proficient computer skills, including Microsoft Word, Excel, Access and Outlook
- Excellent organizational and prioritization skills
- Bilingual (English/Spanish) language proficiency preferred
This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor’s diagnosis of disease.
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: RN, Registered Nurse, Hospice, Home Based Care, In-Home Care